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4sv� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r'Of. :O1 PICE USE': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-j-3ST <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�3 Z3 <br /> ' Cl r¢ _` 7"'' � y (Complete In Triplicate) �I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lc�Al Health District. , <br /> JOB ADDRESS/LOCATION Q/= 8-PLO-WAIS �A! ,6 J� 'T s'll o _ -- CENSUS`f TRACT:�S�!- 57 ' 1 <br /> IV <br /> Owner's Name / / Phone <br /> city Address 7 ' N / 1 f.>. W4 1? V I L <br /> �"'" T - C 1� <br /> Contractor's Name <br /> License # GLC'' Phone <br /> _�f, /�, /� �lt/f'�� �• f" // %f • �"'=-� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / -RECONDITION DESTRUCTION it/ <br /> I�if � <br /> PUYX INSTALLATION / / PUMP REPAIR I Ij PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAidK SEWER LINES x7T Pati Y <br />'I SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT I OTHER <br /> INTENDED USE TYPE QF WELL CONSTRUCTION SPECIFICATIONS C' <br /> Industrial Carle Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing F <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Ji <br /> Rotor Type of Grout 4 <br /> Other y <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> _ . <br /> .—Type <br /> of--Pump it H,P. <br /> ? PUMP REPLACEMENT: / J State Work'Done I <br /> PUMP 'REPAIR: / / State Work Done <br /> �+ .D <br /> FcTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> F I hereby agree to comply with all laws and regulations of. the San Joaquin Logal Health District <br /> and the State of California pertaining to or regulating we11 ''construction... Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use-. , The above <br /> ` informatio true to the best of my knowledge and belief. <br /> _ <br /> SIGNED � TITLE a- <br /> {_ (D /PLOT !PLAN ON REVERSE SIDE) 4 <br /> FOR/, . PARTMENT USE ONLY 'f <br /> PHASE I <br /> ' APPLICATION ACCEPTED BYDATE v <br /> ADDITIONAL COMMENTS: `� P S IT AL INSPECT <br /> PHASE II GROUT INSEECTION u �, . <br /> INSPECTION BY �� : _ DATEy INSPE ATE <br /> -CALL-FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />